3. Ord #2004-2 & 3/1st reading - Laserfiche WebLink

Please answer the following questions to the best of your ability. *Have you ever tested HIV positive? Yes - No - Yes - No Yes - No Yes No Yes - No Yes - No - *Have you ever had hepatitis? *Do you have any allergies? * Are you a diabetic? *Do you have high blood pressure/heart disease? *Do you have epilepsy, seizures, fainting, or dizziness? * Are you a hemophiliac, have a bleeding disorder, or family history of bleeding? Yes- No- *Do you have a history of skin diseases, easy scaring, easy bruising, open sores, skin sensitivities? Yes No * Are you taking any prescription medication other than routine antibiotics, allergy medication, or birth control pills Yes- No- *FEMALES: Are you pregnant? Yes No *Do you currently have a contagious disease i.e., Tuberculosis, Mononucleosis, Pneumonia, or Sexually Transmitted Diseases? Yes- No *Do you now have, or have you ever had problems with your immune system? Yes No - - Have you been hospitalized in the past 12 months? Explain: Are you under the influence of drugs or alcohol? Yes - No Yes No Yes - No *Do you have any serious physical or mental health problems? By my signature below, I certify that I understand and have answered the above questions truthfully and to the best of my knowledge. Signature Date Print name Date of birth Address Phone no. City State_Zip SS# Artist Design/procedure Location of procedure Answering yes to one or more of the above questions may suggest the need to consult a licensed physician as per subparagraphs 5.1 and 5.2 of the Regulations for Body Art Establishments and Operators.